The Relationship Between Uncertainty and Psychological Distress Among Family Caregivers of Patients With Delirium in Intensive Care Units: A Cross-Sectional Survey.

BACKGROUND: Although family caregivers experienced negative psychological symptoms associated with witnessing intensive care unit delirium in their loved ones, there is a lack of clear understanding of how delirium is associated with family caregiver psychological distress. Uncertainty could be a factor contributed to this association. OBJECTIVES: The aim of this study was to examine the relationship between uncertainty and psychological distress among family caregivers of patients with delirium in intensive care units. METHODS: A cross-sectional correlational design was used for this observational study of adult family caregivers of patients admitted to the intensive care unit and who reported witnessing delirium symptoms in their loved ones. Family caregivers completed an electronic survey in January 2022 that consisted of a family caregiver and patient demographic form, the Mishel Uncertainty in Illness Scale-Family Member, and the Kessler Psychological Distress Scale. Descriptive, correlational, and regression statistical analyses were applied. RESULTS: One hundred twenty-one adult family caregivers were enrolled. Family caregivers reported substantial uncertainty (mean, 106.15, on a scale of 31-155) and moderate to severe psychological distress (mean, 31.37, on a scale of 10-50) regarding their witnessing of delirium episodes in their loved ones. Uncertainty was significantly correlated with psychological distress among family caregivers (rs = 0.52, P < .001). Uncertainty significantly predicted psychological distress among family caregivers (regression coefficient, 0.27; P < .001). DISCUSSION: Family caregiver uncertainty was positively associated with psychological distress. This distress can interfere with family caregiver involvement in patient delirium care. These findings are essential to increase critical care nurse awareness and inform the development of nursing interventions to alleviate possible uncertainty and distress.

The problem of comparing nurse practitioner practice with medical practice.

Comparing the practice of nurse practitioners to medical practice began almost 50 years ago and continues to this day. This comparison is curious since the founders of this movement did not indicate that these advanced practice nurses were to be interchangeable with physicians. Nevertheless, substantial literature indicates that nurse practitioners perform equally or better when measured against physician practice standards. This paper compares the ontology and epistemology of both professions and concludes that the philosophical foundations are so different that comparisons are illogical.

The Impact of Stereotype Threat on Memory and Cognition in Older Adults.

Cultural stereotypes that equate aging with decreased competence and increased forgetfulness have persisted for decades. Stereotype threat (ST) refers to the psychological discomfort people experience when confronted by a negative, self-relevant stereotype in a situation where their behavior could be construed as confirming that belief. The purpose of this study was to examine the relationships of ST on memory performance in older adults over 24 months. The ST levels on average significantly declined, or improved in the memory training, but not the health training group. Although not significant at the .01 level, the bivariate correlation indicated that change in ST was moderately related to change in verbal memory, suggesting the possibility that improvements (or reductions) in ST may be related to increases in verbal memory scores. We discovered that the unique contribution of ST into the memory performance of healthy older adults offers a possible malleable trait.

Experimentally evoked pain in Alzheimer's disease.

BACKGROUND: Pain continues to be underrecognized and undertreated in Alzheimer's disease (AD) while existing guidance about pain assessment and management in dementia is not widespread. Brain regions involved in pain processing and modulation are damaged during AD, and the pain experience in AD is not well understood. Experimental pain studies using psychophysics can further our understanding of the pain experience in AD, which may lead to improved assessment and management of pain in people living with AD. OBJECTIVE: A systematic review was conducted to explicate the current understanding of experimentally evoked pain in AD from primary research using psychophysical methods. DATA SOURCES: Peer-reviewed publications were found via PubMed, CINAHL, and PsycINFO. A total of 18 primary research, peer-reviewed full articles that met inclusion criteria were included, representing 929 total participants. CONCLUSIONS: Experimentally evoked pain in people with AD demonstrates that despite cognitive impairment and a reduced ability to effectively communicate, individuals with AD experience pain similar to or more unpleasant than cognitively intact older adults. This may mean amplified pain unpleasantness in people with AD. IMPLICATIONS FOR PRACTICE: Our current best practices need to be widely disseminated and put into clinical practice. Self-report of pain continues to be the gold standard, but it is ineffective for noncommunicative patients and those unable to understand pain scales or instructions because of memory/cognitive impairment. Instead, pain treatment should be ethically initiated based on patient reports and behaviors, caregiver/surrogate reports, review of the medical record for painful conditions, analgesic trials, and regular reassessments.

Could Altered Evoked Pain Responsiveness Be a Phenotypic Biomarker for Alzheimer's Disease Risk? A Cross-Sectional Analysis of Cognitively Healthy Individuals.

BACKGROUND: This study evaluated whether the apolipoprotein ɛ4 (APOE4) allele, a genetic marker associated with increased risk of developing late-onset Alzheimer's disease (AD), was associated with differences in evoked pain responsiveness in cognitively healthy subjects. OBJECTIVE: The aim was to determine whether individuals at increased risk of late-onset AD based on APOE allele genotype differ phenotypically in their response to experimentally-induced painful stimuli compared to those who do not have at least one copy of the ɛ4 allele. METHODS: Forty-nine cognitively healthy subjects aged 30-89 years old with the APOE4 allele (n = 12) and without (n = 37) were assessed for group differences in pain thresholds and affective (unpleasantness) responses to experimentally-induced thermal pain stimuli. RESULTS: Statistically significant main effects of APOE4 status were observed for both the temperature at which three different pain intensity percepts were reached (p = 0.040) and the level of unpleasantness associated with each (p = 0.014). APOE4 positive participants displayed lower overall pain sensitivity than those who were APOE4 negative and also greater overall levels of pain unpleasantness regardless of intensity level. CONCLUSION: Cognitively healthy APOE4 carriers at increased risk of late-onset AD demonstrated reduced thermal pain sensitivity but greater unpleasantness to thermal pain stimuli relative to individuals at lower risk of late-onset AD. These results suggest that altered evoked pain perception could potentially be used as a phenotypic biomarker of late-onset AD risk prior to disease onset. Additional studies of this issue may be warranted.

Policy Implications for Pain in Advanced Alzheimer's Disease.

Untreated pain in people with Alzheimer's disease continues to be a serious public health problem. Pain is a subjective and complex experience that becomes increasingly challenging to assess as cognition declines. Our understanding of pain processing is incomplete, particularly for special populations such as people living with Alzheimer's disease, and especially in the advanced stages of the disease. Pain-processing networks in the brain are altered in Alzheimer's disease, yet evidence suggests people living with Alzheimer's disease do not experience less pain. Rather, their pain is not adequately recognized or treated. Although scholarly publications provide important assistance, recent widespread reports and guidelines do not include sufficient guidance, especially as Alzheimer's disease progresses to the last stages. Additionally, current pain measurements may not accurately evaluate pain in this condition, and the existing definitions of pain are not adequate when considering the effects of Alzheimer's disease on pain-processing in the brain. There is a need for new, widespread policies, guidelines, and definitions to help clinicians adequately manage pain in people with Alzheimer's disease. These will need to hinge on continued research because it remains unclear how Alzheimer's disease impacts central pain processing, pain expression, and communication of pain. In the meantime, policies and guidelines need to highlight current best practices as well as the fact that pain continues in Alzheimer's disease.

Narrative Review of Sensory Changes as a Biomarker for Alzheimer's Disease.

Early recognition of Alzheimer's disease (AD) in the prodromal period has not been robust yet will be necessary if effective disease-modifying drugs are to be useful in preventing or delaying the condition. The objective of this narrative review was to describe the current, evidenced based understanding of alterations in sensory data as potential biomarkers for AD. Review of empirical studies that tested senses as biomarkers for AD and were published in English within the past 50 years was completed. Eighteen empirical studies were identified that met the strict criteria for inclusion, with 12 of these studies being related to the olfactory system. Two studies examined auditory, two examined vision, one examined proprioception, and one examined taste. Thus, only olfaction has been studied to any extent, leaving a clear gap in the literature for the use of other senses. A promising area of research has begun to be reported concerning differences in responses to pain stimuli in AD relative to cognitively normal subjects. Pain is not a single sense like the others but integrates several senses and may allow for use as an early biomarker for AD, as it integrates several brain areas and pathways. Unlike the other senses, simple devices can be used to measure changes in pain perception in cognitively normal adults with genetic predispositions for possible AD, making this potentially useful for clinicians in the future.

An integrative review of system-level factors influencing dementia detection in primary care.

BACKGROUND AND PURPOSE: The incidence of Alzheimer disease (AD) is increasing in the United States, yet more than half of the people with AD are diagnosed late in the course of the disease. Most are identified outside primary care. New approaches to prevention and treatment mean that early detection of AD may improve the quality of life of those affected by the disease. Nurse practitioners (NPs) have an important role in increasing early diagnosis of AD.The purpose of this systematic literature review is to identify health care system factors that contribute to missed or delayed diagnosis of dementia by primary care providers. METHODS: Articles were identified through a systematic electronic search of the following databases: MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Results indicate considerable variation in the diagnostic accuracy of dementia by primary care providers. Missed or underdiagnosis of dementia results from organizational, provider, and patient factors. New treatments are under investigation that may slow the progression of AD much better than current therapy, emphasizing the need to improve early detection by clinicians, especially primary care NPs.

Sex Differences in Associations of Cognitive Function with Perceptions of Pain in Older Adults.

BACKGROUND: Sex differences in pain have been shown to exist in older adults with normal cognition and people with Alzheimer's disease. It is unknown if sex differences in pain in older adults exist in a range of communicative older adults with varying cognitive ability from no impairment to moderately severe cognitive impairment. OBJECTIVE: This study proposes to compare the association between psychophysical responses to experimental thermal pain between males and females to determine if sex differences in pain exist across the cognitive spectrum. METHODS: We conducted a secondary analysis of data from an age- and sex-matched between-groups cross-sectional study examining the psychophysical response to contact heat in people with and without dementia. RESULTS: Median age of males (n = 38) and females (n = 38) was 73 (range: 68-87) with similar distributions of Mini-Mental State Examination (MMSE) scores (range: 11-30). Findings revealed inverse statistically significant associations with the threshold temperature of warmth (females: r = -0.41, p = 0.010; males: r = -0.33, p = 0.044). There was an apparent divergent pattern of MMSE associations with unpleasantness ratings between the groups. At the moderate pain threshold, that difference became statistically significant (p = 0.033). Females demonstrated a positive association of MMSE with unpleasantness (r = 0.30, p = 0.072), while males demonstrated an inverse association at that respective threshold (r = -0.20, p = 0.221). CONCLUSIONS: Between-group findings suggest that patterns of responses to thermal stimulus intensity may differ between males and females with worsening cognition with females reporting significantly less unpleasantness with the percept of moderate pain and males reporting significantly higher unpleasantness with moderate pain perception.

Potential Crisis in Nurse Practitioner Preparation in the United States.

The Doctor of Nursing Practice (DNP) degree was established to expand nurse practitioner education by adding new competencies. In 2004, the American Association of Colleges of Nursing released a position statement that redefined practice from only clinical care of patients to include nonclinical care. This policy position likely contributed to the rapid growth of DNP programs. Historical background on the development of the DNP is provided. An analysis was conducted of the programs reported in the American Association of Colleges of Nursing list of accredited DNP programs between 2005 and 2018 to compare whether the programs prepared graduates for advanced clinical practice or administrative or leadership. During this time, 553 DNP programs were established, 15% (n = 83) are clinical, and 85% (n = 470) are nonclinical. The adequate production of nurse practitioners in the future may be in jeopardy with this imbalance in educational resources, especially with the nation's growing need for primary care clinicians.

Nationwide Doctor of Nursing Practice/Advanced Practice Registered Nurse Survey on Roles, Functions, and Competencies.

Educational preparation for advanced practice registered nurses (APRNs) continues to shift from the master's degree to the doctor of nursing practice (DNP). Previous analysis of the roles, functions, and competencies of APRNs by Honig, Smolowitz, and Smaldone (2011) identified differences in practice between Master's of Science in Nursing (MSN)- and DNP-prepared APRNs. The aim of this study was to use the survey instrument created by Honig et al. to survey DNP/APRNs from across the nation and gain insight into their roles, competencies, and functions. A convenience sample was drawn from DNP graduates from the 13 schools provided by the American Board of Comprehensive Care (ABCC) as eligible to sit for the ABCC examination. A total of 375 individuals from 33 states who reported that they were in practice as a nurse practitioner (NP) completed the survey. Differences between the initial study and this study indicated that DNP NPs currently provide care across settings but with less inpatient care, less subacute care, and less palliative care than was reported in the initial analysis. Pregnancy-related care was the least common clinical service provided. Overall, this research indicates that DNP NPs prepared in comprehensive care are providing direct clinical care across settings to complex patients consistent with the comprehensive care domains for the ABCC certification examination (Honig et al., 2011).

Recommendations From an Early Adopter of a Doctor of Nursing Practice Program.

BACKGROUND: Many changes have occurred in DNP programs since they first began. University of Tennessee Health Science Center began the practice doctoral program in 1999 and today enrolls over 100 new baccalaureate nursing (BSN)-to-Doctor of Nursing Practice (DNP) students each year. More than 500 DNPs have graduated to date. METHOD: A review of the history and challenges of this program are presented as a potential exemplar for other programs to consider. RESULTS: Several changes have taken place, including a shift from Master of Science in Nursing (MSN)-to-DNP programs to almost all BSN-to-DNP programs, a new appreciation for writing skills, and movement away from a separate DNP project. CONCLUSION: Understanding these changes may help other schools of nursing as they begin DNP programs or transition from their MSN-to-DNP programs to BSN-to-DNP programs. [J Nurs Educ. 2016;55(10):563-567.].

Emergency physicians' perspectives on their use of health information exchange.

STUDY OBJECTIVE: We explore what emergency physicians with access to health information exchange have to say about it and strive to better understand the factors affecting their use of it. METHODS: A qualitative study using grounded theory principles was conducted in 4 urban emergency departments that had health information exchange access for 4 years. Data were collected with unstructured interviews from 15 emergency physicians. RESULTS: Emergency physicians reported that a number of factors affected their use of health information exchange, but the most prevalent was that it was not user friendly and disrupted workflow. Five major themes emerged: variations in using health information exchange and its access, influencing clinical decisions, balancing challenges and barriers, recognizing benefits and success factors, and justifying not using health information exchange. The themes supported a theoretical interpretation that the process of using health information exchange is more complex than balancing challenges or barriers against benefits, but also how they justify not using it when making clinical decisions. We found that health information exchange systems need to be transformed to meet the needs of emergency physicians and incorporated into their workflow if it is going to be successful. The emergency physicians also identified needed improvements that would increase the frequency of health information exchange use. CONCLUSION: The emergency physicians reported that health information exchange disrupted their workflow and was less than desirable to use. The health information exchange systems need to adapt to the needs of the end user to be both useful and useable for emergency physicians.

Preliminary findings of the relationship of lower heart rate variability with military sexual trauma and presumed posttraumatic stress disorder.

Decreased heart rate variability (HRV) occurs with physical and psychological disorders and is a predictor of cardiac and all-cause mortality. This study was the first of which we are aware to examine and report the relationship between military sexual trauma (MST) and HRV measures. In a historical cohort study of female veterans with (n = 27) and without (n = 99) MST who received Holter and electrocardiogram evaluation at a Veteran Affairs medical center during 2007-2010, we examined the relationship between MST and the standard deviation of all R-R intervals (SDNN) and the square root of the mean of the sum of the squares of differences between adjacent R-R intervals (RMSSD). Female veterans with MST were younger, p = .002, frequently had a probable posttraumatic stress disorder diagnosis, 80% versus 15%, p = < .0001, and had lower SDNN, p = .0001, and RMSSD, p = .001, than those without MST. The SDNN and RMSSD of a 25-year-old female veteran with MST were comparable to that of female veterans aged 69 to 81 years without MST. Further research is needed to evaluate relationships between MST and HRV measures.

Pain and hospice care in nursing home residents with dementia and terminal cancer.

AIM: One condition associated with severe end-of-life pain that can lead to a poor quality of death is cancer. Cancer pain in people with dementia is of particular concern because of communication problems that occur with worsening disease. The aim of the current pilot study was to examine the association between hospice enrolment, dementia severity and pain among nursing home residents who died from advanced cancer. METHODS: Between-groups cross-sectional chart audits of 55 nursing home residents with dementia who died from cancer were carried out. RESULTS: A total of 45% of residents were in hospice at the end-of-life. Residents in hospice were more likely to receive an opioid (80% vs 43%, P = 0.005); but less likely to show severe cognitive impairment (20% vs 50%, P = 0.050). Enrolment in hospice was associated with an increased likelihood of receiving an opioid after controlling for level of cognitive impairment (OR = 3.9, 95% CI = 1.1-14.0, P = 0.037). Lower levels of cognitive functioning were associated with a decreased likelihood of receiving an opioid after controlling for enrolment in hospice (OR = 0.3, 95% CI = 0.1-0.8, P = 0.030). Notably, 40% of nursing home residents with dementia who died from cancer did not receive any opioid during this time. CONCLUSIONS: Preliminary results suggest that hospice enrolment might be influenced by the facility or region of this particular country. Hospice enrolment predicts more opioid pain treatment in residents with dementia and terminal cancer; however, no resident with very severe dementia and terminal cancer was placed in hospice care. Severely cognitively impaired nursing home residents requiring opioids are at great risk of suffering from untreated advanced cancer pain. New methods are urgently required to improve end-of-life palliative care for nursing home residents with terminal cancer and severe dementia.

The potential of health information exchange to assist emergency nurses.

Health information exchange holds the promise of sharing critical information about patients across organizations. We have found that emergency nurses have little or no involvement in using health information exchange and, often, they are not granted access by individual hospital policies. Yet, emergency nurses need to know this information and must have full access to health information exchange. We provide recommendations to ensure that emergency nurses are able to reach their full potential in using health information exchange to care for patients.

The prevalence of employed nurses identified or enrolled in substance use monitoring programs.

BACKGROUND: For over 100 years, nurses' particular work conditions have been anecdotally associated with increases in substance abuse. Reasons include job-related stress and easy access to medications. Current research has suggested that prevalence of nurses with substance use problems is actually similar to, if not less than, that seen in the general population. However, given nurses' proximity to critical patient care, the potential threat to public health, as well as the current shortage of practitioners and problems related to retention, the lack of research on the effectiveness of the two existing treatment protocols (disciplinary and alternative-to-discipline [ATD]) is a pressing issue of concern to the nursing profession. OBJECTIVES: The aims of this study were to estimate the 1-year prevalence of employed nurses requiring an intervention for substance use problems in the United States and the 1-year prevalence of nurses enrolled in substance abuse monitoring programs and to compare the sum total of nurses identified in disciplinary and alternative programs with the general population. METHODS: This was a balanced stratified sampling design study. Measurements included the National Council of State Boards of Nursing 2010 Survey of Regulatory Boards Disciplinary Actions on Nurses, the 2009 annual reports of alternative programs, the 2008 National Sample Survey of Registered Nurses, and the 2009 National Survey on Drug Use and Health. RESULTS: The 2009 1-year prevalence of employed nurses identified with substance use problems in the United States and its territories was 17,085 or 0.51% of the employed nursing population. The 1-year prevalence of nurses newly enrolled in substance abuse monitoring programs in the United States and its territories was 12,060 or 0.36%. Although every National Council of State Boards of Nursing jurisdiction has a disciplinary monitoring program, only 73% (n = 43) of these jurisdictions have alternative programs. Despite this, on average, alternative programs had nearly 75% more new enrollees (9,715) when compared with disciplinary programs (2,345). The prevalence of nurses identified with a substance use problem requiring an intervention (and likely treatment) is lower than the prevalence of those who report receiving substance abuse treatment in the general population (0.51% vs. 1.0%). CONCLUSIONS: The ATD programs potentially have a greater impact on protecting the public than disciplinary programs because ATD programs identify and/or enroll more nurses with substance use problems, thereby initially removing more nurses with substance use problems from direct patient care.

Prevalence and prevention of paratuberculosis in North America.

The United States of America (U.S.) has made several attempts over the years to develop a producer accepted voluntary program. The focus of the U.S. Voluntary Bovine Johne's Disease Control Program (VBJDCP) is to provide producers with the tools to control Johne's disease on their farms and identify herds with a low risk for the presence of Mycobacterium avium subspecies paratuberculosis (MAP) infection. The VBJDCP includes an evaluation of producers' operations to identify practices that could allow the transmission of MAP among animals or between premises. Once risky practices havebeen identified, a herd management plan is developed to assist the producer in correcting risky practices. In addition to management changes, vaccination is a control tool allowed in the U.S. because it reduces the clinical signs of Johne's disease and the shedding of MAP. Testing is used in addition to management changes. While the classification component of the VBJDCP dictates the amount and type of testing herd owners are required to conduct, the education and management components of the VBJDCP does not specify testing protocols. The testing for control is intended to fit the needs and resources of producers and can be quite flexible. Management changes on the farm remain the key to control and programs cannot replace well thought out plans by producers that are specific to their resources, facilities, and operation.